Prehospital Volume Therapy as an Independent Risk Factor after Trauma

Abstract

Background. Prehospital volume therapy remains widely used after trauma, while evidence regarding its disadvantages is growing. The primary objective of this study was to investigate the volume administered in a prehospital setting as an independent risk factor for mortality. Material and Methods. Patients who met the following criteria were analyzed retrospectively: Injury Severity Score = 16, primary admission (between 2002 and 2010), and age = 16 years. The following data had to be available: volume administered (including packed red cells), blood pressure, Glasgow Coma Scale, therapeutic measures, and laboratory results. Following a univariate analysis, independent risk factors for mortality after trauma were investigated using a multivariate regression analysis. Results. A collective of 7,641 patients met the inclusion criteria, showing that increasing volumes administered in a prehospital setting were an independent risk factor for mortality (odds ratio: 1.34). This tendency was even more pronounced in patients without severe traumatic brain injury (TBI) (odds ratio: 2.71), while the opposite tendency was observed in patients with TBI. Conclusions. Prehospital volume therapy in patients without severe TBI represents an independent risk factor for mortality. In such cases, respiratory and circulatory conditions should be stabilized during permissive hypotension, and patient transfer should not be delayed.

Factors associated with death or volume replacement in patients with trauma due to penetrating injuries

“…This research agrees with the assumption that in cases where the volume replacement exceeds 2000ml there is more mortality as the level of statistical significance of the T-Student test infers that there is a relationship between the infused volume and patients' death, considering p value <0.05. Perhaps this is related to the fact that excess liquid would significantly contribute to the difficulty of adjustment of the body, reducing its defense capability, accelerating the hemorrhage before the increase circulating volume and impairing microcirculation and tissue oxygenation, thus requiring more attention of health professionals with the circulatory and cardiovascular systems (6)(7)(8)10,(16)(17) .…”

“…Trauma caused by penetrating injuries may lead to severe internal bleeding, because especially the trunk lesions, which affect heart, liver, spleen, kidney and large vessels areas, tend to be lethal due to the rapid evolution. The identification of the etiology and prompt treatment are crucial to reduce morbidity and mortality, and the adoption of strategies aimed at improving the management of victims of penetrating trauma are of paramount importance (1,(5)(6) .…”

“…Volume replacement has proved to contribute significantly in the probability of survival, since it may be associated with lower occurrence of shock by its function of maintaining hemodynamic balance, tissue oxygenation and by restoring tissue perfusion and functionality of various organs and systems (6)(7)(8)(9) . The correction of the deficit in intravascular volume aims to improve myocardial performance by increasing end-diastolic volume, optimizing oxygen transport.…”

“…The shock is usually established when there is hypoperfusion of vital organs, causing that the body tries to compensate it by activating the sympathetic branch of the autonomic nervous system, causing peripheral vasoconstriction, tachycardia and increased myocardial contractility, triggering increased oxygen demand (6,10) .…”

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“…It is known that bleeding trauma patients who initially received more than 2 liters of fluid for resuscitation compared to a low volume group had a significantly worse coagulation profile, required more blood products and had higher incidence of organ failure 22 . Thus, extended prehospital fluid therapy in severely injured trauma patients can be considered as an independent risk factor for mortality 23 .…”